Category “Invisalign”

Invisalign versus implant therapy

Case presentation: Invisalign versus implant therapy

Every day we are faced with challenging cases. Should we extract, file down or build up?

But with experience one begins to understand which treatments work, which are too outlandish and which should never have been started.

However when a tooth is destined for removal then the resultant space presents a dilemma.

Should we restore the space or should we prepare adjacent teeth for a bridge and thereby reduce the life expectancy of these teeth as well.

Restoring a space has evolved from dentures to the use of dental implants, mini or maxi. Even if a mini implant can be used, does the patient want implants and will there be adequate space for a reasonably life like crown?

It seems logical that if the space is too small to restore then we should try to close the space instead of opening it up for an implant. This option is gentler, quicker and less expensive.

A delightful lady was referred to me for an opinion on how to restore a failing UR2 post crown.

She came with her husband and I have to say that we got on right from the start.

The lady was 60 years of age and in good health. Her dentition was relatively unrestored and she had good oral hygiene.

Her brother in law was a dentist and had read one of my articles on Invisalign and hence referred the patient to me for a solution.

She presented as follows:

  • Class 2 skeletal base
  • Class 2 div 2 dental crowding
  • RHS canine was full class 2 and rotated
  • LHS canine was half class 2
  • Overbite was slightly deep
  • Centrelines incoincident
  • Arch collapse laterally especially RHS with slight open bite
  • Upper central incisors were retroclined and the laterals were crowded

Initial presentation:

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UR2 had been prepared to bring it into the arch 35 years ago with a metal porcelain post crown.

It was very long and had a tapered crown. The length signified that the tooth must have sat very high labially but would have been short at the incisal edge.

It had a vertical root fracture and was beyond saving. The problem was that the root was still outside the dental arch and the interproximal space was about 3mm.

There was no room for a dental implant so the options discussed were:

  • Orthodontic distalisation of RHS segment to create space for an implant
  • Cantilever bridge from UR3 with a similar pontic
  • Fixed UR13 bridge
  • Denture
  • Close space orthodontically

As the patient had class 2 div 2 dental crowding I advised the patient that we could use Invisalgn to:

  • Upright the centrals
  • reduce the overbite
  • correct lateral arch collapse
  • correct lower crowding
  • close UR2 space
  • preserve her natural teeth

The problems that I had were as follows:

  • Would the gap close?
  • Would the gum line be uneven?
  • Should I have waited for soft tissue maturation?
  • Will uprighting her arch create more space when we are trying to close a space?
  • Would the patient accept the attachments?
  • UR3 class 1 was not going to be the goal here
  • Correcting centre line would have created more space RHS to then have to close

Patient agreed on Invisalign treatment as she wanted to preserve her natural teeth. She was happy not to correct the centre line because her UR2 space closure was her priority.

Her brother in law removed the UR2 and she came in for impressions.

Invisalign scans were produced and the images are shown as below:

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There were 28 upper and 11 lower aligners. The treatment included :

  • Arch expansion by derotating 654/456
  • There was some IPR required LHS to improve the canine position
  • Uprighting central incisors
  • Intruding upper incisors to reduce overbite and bringing the UR1 closer to UR3
  • Intruding lower incisors to flatten occlusal plane
  • Derotating UR3 mesially towards UR2 space

The aligners were custom made for each individual stage and there was no pontic allowed UR2 due to lack of space.

The patient changed each aligner every 2 weeks and came on Saturdays every 8 weeks for a review.

Her oral hygiene was impeccable and she had only 1 problem and that was a slightly dry mouth with the aligners.

The space was less noticeable with the aligners in due to the natural reflection of the material.

The patient had no problems in removing the aligners and she started to notice how her smile widened with throughout the treatment.

Once the lower treatment aligners were finished we carried out some minor refinement.

After approximately 15 months the treatment was finished.

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You will notice that the UR2 space closed completely and moving the canine mesially created an incisive papilla. Lower gum line is even as well. The occlusal photo shows a nicely rounded arch.

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“The teeth are still looking good, I am really pleased that I had them done, money worth spending ( one less holiday!)”

Conclusion

If a patient has had healthy teeth for over 55 years then why would she want them filed down for a bridge? It is never too late to do Invisalign.

Using Invisalign to treat a dental phobic who wants braces

A dental phobic is a person afraid of anything to do with dentists. These phobics are happy to brush and floss but fail to attend for dental treatment for fear of needles and also the drilling procedure.

Case presentation

The following is a case of a young 19 year old female who as a needle phobic had avoided vaccinations, dental injections and had even bit her last dentist on the finger.
She presented with her mom in desperate need of orthodontic treatment.

Naturally she had not accepted dental extractions and fixed orthodontics as a teenager but was now keen to be able to smile.

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She was an attractive young girl who did not like to smile.
After careful consideration of her dislike of dentistry and for not losing a finger I examined her and found her suitable for Invisalign treatment.

The patient was a mild class 2 dental and on a class 1 skeletal base

UR3 was half class 2/ UL3 was class 1 leading to a proclined UR1

Centrelines were acceptable

Oral hygiene needed improving

I wanted to reduce the amount of dental procedures for her so I decided:

  • No extractions
  • No interproximal reduction
  • Attachments were delayed for 6 months
  • Upper arch space was created by distalising the molars
  • Lower arch space was created by arch expansion
  • The distalisation of the molars is only possible if the third molars are missing or oven unerupted
  • There were 35 upper and 17 lower aligners

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I saw the patient every 6-8 weeks with no problems or tantrums.

At aligner 11 after molar distalisation, the premolars are then distalised allowing the anteriors to start correction.
At the end of the treatment of 18 months I was so happy that we agreed to remove the attachments and then take impressions for retainers.

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Unfortunately the dental phobic had spent the last year on Google and had become obsessed with her teeth. She wanted them even straighter and had asked for a second opinion.
Another dentist not knowing how nervous she had been recommended further anterior correction, which would have involved IPR.

She came back to the surgery and started shaking and crying in front of me. I was annoyed as I had already ordered the retainers and this precluded further refinement.

So I was surprised by her change of heart as I had thought that she would be happy just having them straighter. But I was wrong as she wanted the straightest.

I agreed to pay for Invisalign Lite (14 aligners) and she agreed to pay for new retainers.
The upside was that she did refer her mother for Invisalign as well.

The refinements were 7 aligners in total and again no IPR.
She then did not attend for over 15 months and decided to treat herself with the aligners.

After that period the patient attended wanting even more retraction of the UR1, but I refused to bend to her wishes. I commented that she was non- compliant and that if she wanted more work then she should see that other dentist.

After 45 minutes of deliberation and mediation with her mother she agreed to retainers and only after I had contoured the incisal edges of at least 8 anterior teeth.

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The patient did have a soft tissue triangular space between 1/1 but that could only be reduced with
aggressive IPR.

The final alignment actually looked worse than the refinement but this was because the patient never attended for reviews.

Invisalign when used to its full potential allows the dentist and patient to benefit from full spacecreation and minimal IPR.

When treatment planning involves the patient then Invisalign can convert the dental phobic into a fully committed dental patient.

Orthodontic referrals can be forwarded to info@forma.co.uk
Dr R Kumar is conducting national seminars on removable orthodontics and Invisalign certification and enquiries can be forwarded to info@forma.co.uk

Dr Raj Kumar BDSLDSRCS

Invisalign; when to take a tooth out

Dental crowding is an issue of too many teeth and not enough space.

Why is that?

Are we normally born with too many teeth? The answer is No! What has happened is that the size of our dental arch is either developing into a smaller arc, or our dental arch is being constricted.

The latter is usually the case. As we stress over our studies, partners, work and health, we tend to clench and grind our teeth.

The action of our chewing muscles on the teeth causes movement inwards and constriction, leading to dental crowding.

So with Invisalign I usually expand the dental arch to create space, but not always.

Sometimes it is easier to take out the offending tooth and then straighten the teeth

See below, a severely crowded lower arch, corrected by Forma with Invisalign in just over 10 months. The outer tooth was removed first and Invisalign worn night and day.

 

Do you treat yourself to a television or a better smile?

Dental crowding is a major factor in low self esteem, low confidence, bullying, hiding behind your peers, lack of social contacts and even a better spouse!
So if teeth are such trouble then why don’t we do something about it?
Let’s imagine the 46″ Sony Plasma is looking a little jaded and the picture looks so fuzzy that you thought that England had just scored 5 goals?
Well you thought wrong, that was Germany.
So now it’s time for High Definition TV.
So you drag your wife ( as it’s usually men who buy big TVs ) to the local Comet and convince her that you need a HD LED 50″ Sony.
So that evening the TV is placed on a wall bracket and they both watch Top Gun in HD.
As a thank you he has an early night and they have some fun.
Problem was that he has bad breath and his teeth are very crowded, she can taste his meal on his teeth.
So the moral of this little story is you cant take your high tech HD TV with you to bed.
If you have a dental problem and your spouse is kind enough to point it out, then at least look into sorting it out before your adorn your house with the latest gadgets.
Here is an example of how Forma Dental can make a difference.

Good reason when veneers supersede orthodontics

Teeth if they are perfectly healthy, intact and of good appearance, BUT are in the wrong place, should be moved orthodontically.

But what about teeth that are just too broken down/heavily filled to be ignored?

As one gets older and especially patients born pre 1980s there are lots of anterior composite fillings present from all those fizzy drinks we used to have.

Post 1950 there was a big sugar rush; sugar was in everything including healthy fruit juices, baby bottle drinks and even hidden in processed foods.

So as a sugar consumer, you have to be great at brushing and flossing away food particles and germs.

Germs digest sugars and produce acids as by products, which causes tooth enamel erosion and cavities.

The teeth get filled but the patient continues the abuse and thus the enamel edges around the fillings begin to rot as well. Thus fillings get bigger and the teeth get weaker.

White composite fillings when first done blend very nicely with the surrounding teeth, but over time they do absorb stains etc.

There comes a time when the fillings are too big to be replaced and it is then that we should think about more permament solutions.

Porcelain veneers replace the front and sides of the tooth by 1-1.5mm. Porcelain crowns replace the back as well.

I only advocate porcelain veneers/crowns if the teeth are relatively straight; some minor crowding imperfections can be corrected during the veneer preparations.

Now remember, once your teeth are filed, you cannot put the enamel back. So make sure the dentist is confident that the teeth need veneering.

Most teeth will need preparation of 0.5mm or more in order to create space for veneers that are within  the natural contours of the teeth.

Sometimes you can have veneers that are too thick and the patient can look slightly horsey.

Here is a case of mine where it is evident that the teeth are heavily filled, patient is mid 30s and she would like a nicer smile.

The teeth were prepared and temporaries were placed. Chameleon Fortress porcelain veneers were then placed.

Red lipstick always enhances my work. Hope you like the transformation.

For example:

 

When is a consultation a waste of time?

As a teenager or an adult you have usually had all your permanent teeth come through and in most cases they are misaligned or sometimes spaced.
As we are not related to sharks that have numerous sets of teeth, then we must look after our 1 set.
Be it by watching our sugar intake or brushing the teeth regularly we can make an attempt at looking after our teeth.
But when something goes wrong then we have to employ the services of a dentist.
We are at the mercy of the dentist, his skills at examination, assessment, explanation and execution.
So when a patient enquires at what can be done with their crooked teeth, then there are 3 types of patient consult:

1 The patient has no idea of what options there are and wants the advice of the dentist
2 The patient has some idea of the options from having visited other dentists and wants a 3rd or 4th opinion
3 The patient knows exactly what they want from meticulous research/consultation and tells the dentist what they want

Now as a seasoned dentist with 22 years of experience I am rarely told what to do. I have a wealth of experience, opinion, tried and tested methods etc.
So the patient would benefit from my consult.
The problem is the last patient consult type. They know what they want but they want to mine information from me and then find the cheapest dentist around.
Cheaper does not mean better. The product may be the same, but it is how the product is used that make the difference.
So back to my no obligation consult. Having assessed the patient, taken photos, shown said photos, shown similar finished cases, I have proved that I can do the job.
The patient is enlightened, in fact in awe of my skills.
I do not ask for a decision there and then as the patient needs to reflect on their decision ( it’s not like you are buying a TV! ).
Now when I do Invisalign I do the whole mouth treatment and not just the front 6 teeth.
My philosophy is that the anterior crowding has happened because of back of the mouth crowding/collapse. So to ignore it is very short sighted.
My fees reflect the long term, no quibble commitment.
But there are many dentists offering Invisalign but only the anterior version.
So how do they make space?
By filing inbetween the front teeth. The front teeth, especially the lowers are
narrow and overlapped. To file between crooked teeth means losing lots of enamel.
SO I create space at the back to alleviate anterior crowding.
This is FULL INVISALIGN which is longer in terms of treatment and number of aligners.
So I am bemused when patients think they are getting the same treatment as mine for a 50% reduction.
Invisalign like many dental treatments is a complex, fully committed method of straightening teeth, so why belittle it?
It is not like you are buying a sofa set or a 3D television that has a short life expectancy.
Your teeth are for life, so treat them with respect.
Private orthodontics involves
full planning
about 12months of treatment
no quibble guarantee treatment
refinement at the end
full set of retainers
and costs about £3-4000
When patients run off to a Groupon campaign they really are letting themselves down.
Do the research, read the reviews and expect to pay above £3000.
Below is an example of a case finished within 6 months leaving the teeth with uneven stripped edges.
NOT DONE BY FORMA!

Invisalign for international patients

Invisalign is not available in many countries and yet patients want it.
Recently I treated a patient who was in fact English, but worked in Hong Kong.
His dilemma was that he did not like his teeth/smile and yet could not walk around mid 40s wearing metal braces. He wanted an aesthetic/removable solution.
I assessed him to severely crowded with an underbite ( which is technically an overjet where the lower jaw was set back ).
We spent an hour assessing his occlusion and I advised him that to reduce the underbite and correct the severe crowding I would need to remove 2 upper premolar teeth.
As he could not attend every 4-6 weeks, I placed him on a 2 month review programme with a leniency of 2 more weeks.
I was able to do that because of 3 things:
1 Because I am great at what I do lol
2 Extractions creates space that can be accurately measured by Align Tech. and the planning is more predictable
3 I would not need to do any interproximal stripping on a regular basis
So we agreed to start.
I noticed some cavities around the premolars and advised him to have them treated in Hong Kong.
Whilst the clinchecks were being programmed from the impressions I removed the 2 lower teeth under local anaesthetic.
Aligners were fitted initially with no attachments for 8 weeks, as his crowding was so severe and he was going to be away.
During the year treatment the patientt switched from HK to Africa and Libya but this presented no problems to his treatment.
As his extraction spaces closed, his anterior crowding began to correct itself.
I reviewed him every 8 weeks and he had no problems in scheduling his appointments in advance.
A year has passed and he is at the refinement stage. New impressions were taken for minor anterior correction.
See what you think.

 

My first Invisalign consult………….who never came back!

I was so broke in 2004,spending money left right and centre ( or on upper left, lower right and central incisors ) that I had to find a way out of my predicament.
An orthodontist had introduced me to INviisalign by playing their corporate video.
I was so impressed that an general dentist could do ortho that I signed up.
I did the 2 day course, but being in an overdraft scenario I could not prepay the course, so Alison would not give me my certificate 🙁
Eventually my cheque went through and I was a certified Invisalign Monkey.
Anyway my first patient came in through the door and wanted a consultation on upper and lower veneers.
He had proclined teeth with multiple gaps and large fleshy lips. He was causasian.
I could have made £15-20,000 but I told him:
His teeth stick out
He has very large gaps
If I do veneers I cannot bring in the teeth much
and the veneers will be too big for his already wide mouth
In fact he would have looked like the Mask (Jim Carey)
So without hesitation I took his money and did 20 veneers ……
Just joking.
I told him with my hand on my heart that he needed braces. I told him that he would be my first case and that Invisalign would be perfect for him.
He handed over £4000 and I took impressions.
I fitted his aligners, but he never came in for reviews.
I was dying to see the progress but never got to see the results.
I rang him to enquire and he just said that all was progressing nicely and that he was happy.
So my first case, but no photos.
Gaps are so easy to close with Invisalign that I can close them with my eyes closed. |Next time I will show you a case that I did in 2 visits only.
Below is the initial scan of my first Invisalign patient and the hopefully finished case.

How to close a gap and build up a broken tooth with Invisalign

Over time teeth can move and the bite can become uncomfortable or traumatic. Sometimes the bite can cause teeth to wear down or chip resulting in uneven sizes teeth.
The following case presented with a young male aged 30 who had a traumatic bite that was slowly wearing away his front tooth. On top of which he had a moderate sized front gap.
The arch was narrow so we had to expand the arch, which naturally opens up the space at the front as well as close this space.
With Invisalign we decided to bring the front upper teeth together and upwards so as reducing the overbite and trauma to the teeth.
The treatment took 1 year as we had to treat the whole upper and lower arches.
The edges of the teeth are now level but the gum line of the lhs tooth is higher as this tooth was longer. He had a low smile line so this was not a problem.
We opted to have level incisal edges instead of trying to build up the broken edge, which would have meant constant repair/surveiilance/care of the tooth edge.
Patient was very happy to have not had the front tooth repaired and was very happy with the outcome.
Conclusion: Invisalign can help restore tooth length by moving the teeth.

 

Getting straight teeth with Forma/Invisalign before my wedding

As a cosmetic dentist I always felt uncomfortable about filing down teeth for porcelain veneers, and more so with younger patients.

I treat a lot of brides getting married within the next 6-12 months. These ladies know that the wedding pictures, in this digital age are scrutinised even more now, and the brides want to look their best.

So for the last 8 years I have being using Invisalign to straighten teeth, close gaps and make people smile.

In fact 95% are female and hardly any grooms!

Here is an example of a lady late 20’s who was engaged for over 3 years, but never had the time to plan the wedding. She knew that her lower incisors were rotated and it bothered her. So she asked me if she could have  them straightened? I said yes with Invisalign and she agreed to have treatment.

Within 2 months she had decided to tie the knot (and not with floss) and then told me she had 8 months to improve her smile.

So we pressed on and over 10 months she got a smile that she could be proud of for her wedding. We removed some of the attachments and gave her tooth whitening gel so she could whiten her teeth before the wedding.

We took impressions for a minor refinement and the new aligners will be fitted after her honeymoon.

 

Invisalign is a non invasive, painless way to get the smile that you always wanted without damaging your teeth.